On imaging alone, the diagnosis is not clear. The differential is wide and includes:

• an infiltrative process (e.g. leukemia) although the distribution, symmetry and proximal femoral sparing is against this
• a storage disorder (e.g. Gaucher disease) although a normal radiograph makes this much less likely (expect Erlenmeyer flask)
• a chronic inflammatory disorder (e.g. CRMO)

A biopsy was performed which yielded inflammatory cells only and based on the that, and the imaging, the child was treated for CRMO.

On treatment, symptoms improved.